The Incident Management function of the wider QPS Incident Management Team is responsible for the development of structures and processes for the effective management and review of incidents to improve patient safety.
What we do
Development and provision of training and support in relation to incident management and review, the development of guidance and tools, and the implementation of a Just Patient Safety Culture throughout the HSE. The Incident Management team works closely with academic partners, leaders in the field of Incident Management and the other functions within the Incident Management Team and the wider QPS Directorate to achieve these aims.
Incident Management Framework
- HSE Incident Review Service User Information Leaflet (The service user information leaflet is under review currently and will be updated promptly)
- HSE Incident Review Staff Information Leaflet.pdf (size 6 MB)
- Independent Healthcare Record Review Template Nov 2020.docx (size 39.2 KB)
- Preliminary Assessment Template Nov 2020.docx (size 58.5 KB)
- Pseudoanonymisation Codes Template Nov 2020.doc (size 676.4 KB)
- System Analysis Review Report Template Nov 2020.docx (size 661.1 KB)
- System Analysis Review Report Checklist Revision 2 23.3.22.docx.docx (size 146.1 KB)
- Yorkshire Contributory Factors .docx (size 347.9 KB)
Launch Presentation and Recordings
In order to view the Webex, please enter password 5aKSWJHQ.
To note, the CEO recording is not available on the Webex recording, we have uploaded it as a separate file.
Review of Pressure Ulcer Incidents
Review of Service User Falls Incidents
Review Tool Healthcare Associated Infections (HCAI)
- HCAI Review Tool Generic.docx (size 86 KB)
- HCAI Review Tool SA.docx (size 98.6 KB)
- HCAI Review Tool Severe CDI.docx (size 86.7 KB)
- PPPG Procedure for the utilisation of Review Tools (RTs).pdf (size 751.1 KB)
- Worked example HAI Review Tool Generic.pdf (size 476.3 KB)
- Worked example HAI Review Tool SA.pdf (size 483 KB)
- Worked example HAI Review Tool Severe CDI.pdf (size 617.2 KB)
After Action Review (AAR)
- AAR Guidance For Services .pdf (size 922.5 KB)
- After Action Review – Staff Information Leaflet
- AAR Summary Report Template 2020.docx (size 16.3 KB)
How to conduct an AAR - Resource Videos (To access click links below)
Look Back Review Process Guideline
Patient Safety Stories
HSE and the Department of Health Communication Protocol
The HSE informs the Department of Health (DoH) of major/significant patient/service user safety incidents and issues of concern. The protocol is currently being updated.
Incidents or issues are escalated by Community Healthcare Organisation (CHO) Chief Officers to the National Director for CHOs who then forwards this via their QPS team to the National Quality and Patient Safety Incident Management (QPSIM) team when deemed necessary. Hospital Group CEOs escalate incidents or issues to the National QPS Office in Acute Operations for consideration and discussion, and as applicable the HSE Internal Escalation Protocol is triggered and forwarded to the QPSIM team. QPSIM then liaise with the DoH and support any follow-up correspondence with the relevant parties. Please contact the national offices QPS Acute Operations, QPS Community or QPSIM@hse.ie for further information.
The referral form can be found here.
Application to the Forum for Post Graduate Training Bodies for nomination of an external expert support
- Procedure for requesting external specialist support from the Forum of Irish Postgraduate Training Bodies for HSE Systems Analysis and Lookback Reviews
- Request form for requesting external specialist support from the Forum of Irish Postgraduate Training Bodies for HSE Systems Analysis and Lookback Reviews
- Request form for the provision of a Healthcare Record Review from the Forum of Irish Postgraduate Training Bodies
Connect with us
Email the Incident Management team: QPSIM@hse.ie